Stridulous Child

Jeremy D. Prager and Charles M. Myer III

History

A 4-month-old girl is transferred to a tertiary pediatric hospital for otolaryngology consultation for a chief complaint of progressively worsening “noisy breathing” for 3 weeks. Her breathing has been worse when she is agitated. She has been feeding well and gaining weight appropriately. Changing her position does not alter her breathing. She has had no apnea, cyanosis, or sick contacts. She is an only child and is not known to have ingested anything other than formula. She has undergone no previous operations or intubations. Delivery was by cesarean section.

On physical examination, a well-developed infant is noted to be in no acute respiratory distress and comfortable in her parent’s arms. Her respiratory rate is normal for age, and she is without nasal flaring or supraclavicular or subcostal retractions. Her cry is not hoarse or high pitched. Auscultation of her neck reveals a mild biphasic stridor, which becomes audible and increases in intensity when she is agitated. Inspection of the head and neck reveals a small cutaneous hemangioma on the right anterior neck skin. Flexible nasopharyngoscopy at the bedside demonstrates a normal supraglottic and glottic airway and fullness in the left subglottic region. The vocal cords are mobile. The patient’s anteroposterior neck film reveals mild left subglottic narrowing. The trachea appears normal. A chest radiograph is normal without hyperinflation or mediastinal shift. Microlaryngoscopy and bronchoscopy are planned. The patient is started on a systemic steroid (e.g., prednisone 2–3 mg/kg/day).

Differential Diagnosis—Key Points

1. Airway complaints, especially those in young children, are some of the most challenging consultations for otolaryngologists. Quick assessment of the patient is required, noting the ABCs (airway, breathing, and circulation) of critical care. Within moments, it is possible to place this patient into the “not acutely ill” category.

2. This patient’s symptom is progressive biphasic stridor. On physical examination and imaging there is suggestion of asymmetric narrowing in the subglottis. Incidental note has been made of a cutaneous hemangioma. No signs or symptoms of acute inflammation, such as fever to support the diagnosis of croup, epiglottitis, or bacterial tracheitis, are seen.

4. Consideration of foreign-body aspiration is obligatory in children with respiratory complaints. This patient’s clinical course is not consistent with foreign-body aspiration.

5. Given the above key points, microlaryngoscopy and bronchoscopy are required to evaluate the subglottis and tracheal airway.

Test Interpretation

Anteroposterior neck films can demonstrate subglottic and tracheal narrowing. The classic anteroposterior neck film is that performed for croup, in which case the subglottis is usually narrowed circumferentially and comes to a superior point (the “steeple sign”). The neck film on this patient revealed a mild narrowing of the left subglottic region and no tracheal narrowing, most consistent with a diagnosis of subglottic hemangioma.